A list of the most recent deficiencies for Woodlands Healthcare Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Conduct testing and exercise requirements. | Fire Safety | 2023-10-18 | 2023-11-26 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2023-10-18 | 2023-11-26 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-10-18 | 2023-11-26 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2023-10-18 | 2023-11-26 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-10-18 | 2023-11-26 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2023-10-18 | 2023-11-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-18 | 2023-11-26 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-10-18 | 2023-11-26 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-10-18 | 2023-11-26 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-10-18 | 2023-11-26 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-10-18 | 2023-11-26 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2023-10-18 | 2023-11-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-10-18 | 2023-11-26 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-10-18 | 2023-11-26 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-10-13 | 2023-11-01 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-10-13 | 2023-11-01 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2023-10-13 | 2023-11-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-13 | 2023-11-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-13 | 2023-10-26 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-10-13 | 2023-10-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-13 | 2023-10-25 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-10-13 | 2023-10-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-13 | 2023-10-20 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-17 | 2023-09-18 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-04-05 | 2023-04-20 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-12-21 | 2022-01-05 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-12-21 | 2022-01-05 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2021-12-21 | 2022-01-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-12-21 | 2022-01-05 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-12-21 | 2022-01-05 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2021-12-21 | 2022-01-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-12-21 | 2022-01-05 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-12-21 | 2022-01-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-12-21 | 2022-01-05 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2021-12-21 | 2022-01-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-12-21 | 2022-01-05 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-12-17 | 2022-01-04 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-12-17 | 2022-01-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-17 | 2022-01-04 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-12-17 | 2022-01-04 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-17 | 2022-01-04 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-12-17 | 2022-01-04 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-12-17 | 2022-01-04 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-12-17 | 2022-01-04 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-12-17 | 2022-01-04 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-12-17 | 2022-01-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-12-17 | 2022-01-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-12-17 | 2022-01-04 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-12-09 | 2021-12-22 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2020-02-28 | 2020-03-27 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-02-28 | 2020-03-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-02-28 | 2020-03-27 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-02-28 | 2020-03-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-02-28 | 2020-03-27 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-02-28 | 2020-03-27 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2020-02-13 | 2020-03-09 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-02-13 | 2020-03-09 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2020-02-13 | 2020-03-09 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-02-13 | 2020-03-09 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2020-02-13 | 2020-03-09 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2020-02-13 | 2020-03-09 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2020-02-13 | 2020-03-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-13 | 2020-03-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-02-13 | 2020-03-09 | N |
